A new approach to gathering pharmaceutical market data to support policy implementation and access to medicines: as demonstrated by malaria medicines in Zambia.

BACKGROUND: The steady supply of quality, affordable medicines is a pillar of a functioning health system. In addition to the public sector, the private, mission and not-for-profit sectors often serve a large part of the population in Africa. However, while there is generally systematic recording of public sector supply of medicines, detailed, systematic and reliable national market data including these non-public sectors are not commonly available in most countries in Africa. Understanding the total market is a missing part of the access puzzle: without this information, policy makers and health practitioners are not able to fully measure the impact of interventions, measure access to effective products, or fully evaluate the rational use of medicines. This article reports on a unique innovation which provides routine, national-level data on the total pharmaceuticals market, through a system which can be replicated elsewhere. It demonstrates how national-level market data contribute to the evidence base for policies on access to essential medicines, using the Zambian anti-malarial medicines market as a case study. METHODS: A new, routine national database on pharmaceutical market size and structure was established through a multi-partner collaboration. Information was extracted from import authorizations and allows for information on local manufacture. Data included value and volume of products as well as pack details, manufacturer and importer. The system was continually updated: data for this analysis were extracted for 6 years: 2009-2014 inclusive. Data were analysed using Microsoft Excel and validated against other sources including donor procurement data. Analysis included public and private sector markets. The policy relevance was demonstrated through analysis of four aspects of national policies on access and rational use of malaria medicines: (i) volume of product relative to disease burden; (ii) distribution by sector relative to treatment-seeking; (iii) consistency of products with respect to national policy guidelines; (iv) market concentration as a proxy for security of supply. RESULTS: The system developed provides the first accurate, systematic data on the breakdown of a national pharmaceutical market in an African context. The total value of the anti-malarials market in Zambia, including all sectors, was USD 5.5-6 million. This included 22 different molecules or combinations, produced by 56 different manufacturers, with 142 different permutations of molecule/manufacturer/strength. Such data provide a complementary mechanism to confirm key trends in malaria treatment and control in Zambia: (i) sufficient supply relative to disease burden, (ii) value and volume of the private/non-profit sector; 29%-2% of market value and 17%-2% of market volume (from 2009 to 2014), (iii) dominance of the 3 molecules recommended in the national treatment guidelines; and (iv) an evidence-base for national discussions on medicines quality, security of supply and rationale use. The system extracts information on all medicines and therefore could be used to analyse other therapeutic classes. Data have been used for several policy purposes, notably by ZAMRA to monitor the quality of products in Zambia, monitoring implementation of WHO Resolutions on artemisinin monotherapy as well as monitoring trends in product choice across sectors. CONCLUSION: Routine data are important for researchers and policy makers alike. This study shows how medicines data can be systematically gathered at national level-comprising range, volume and value in the public, private and not-for-profit sectors-to monitor more detailed trends in the market and allows triangulation of supply-side data against other sources. This systematic approach can contribute significantly to support access to medicines, monitor treatment and public health policies and create healthy markets. It can be used to monitor changes between therapeutic areas, for example the impact of improved malaria treatment on the use of antibiotics in the context of anti-microbial resistance monitoring. As data contain commercially confidential information, appropriate safeguards should be put in place to balance public health and commercial interests.

Closing the access barrier for effective anti-malarials in the private sector in rural Uganda: consortium for ACT private sector subsidy (CAPSS) pilot study.

BACKGROUND: Artemisinin-based combination therapy (ACT), the treatment of choice for uncomplicated falciparum malaria, is unaffordable and generally inaccessible in the private sector, the first port of call for most malaria treatment across rural Africa. Between August 2007 and May 2010, the Uganda Ministry of Health and the Medicines for Malaria Venture conducted the Consortium for ACT Private Sector Subsidy (CAPSS) pilot study to test whether access to ACT in the private sector could be improved through the provision of a high level supply chain subsidy. METHODS: Four intervention districts were purposefully selected to receive branded subsidized medicines - "ACT with a leaf", while the fifth district acted as the control. Baseline and evaluation outlet exit surveys and retail audits were conducted at licensed and unlicensed drug outlets in the intervention and control districts. A survey-adjusted, multivariate logistic regression model was used to analyse the intervention's impact on: ACT uptake and price; purchase of ACT within 24 hours of symptom onset; ACT availability and displacement of sub-optimal anti-malarial. RESULTS: At baseline, ACT accounted for less than 1% of anti-malarials purchased from licensed drug shops for children less than five years old. However, at evaluation, "ACT with a leaf" accounted for 69% of anti-malarial purchased in the interventions districts. Purchase of ACT within 24 hours of symptom onset for children under five years rose from 0.8% at baseline to 26.2% (95% CI: 23.2-29.2%) at evaluation in the intervention districts. In the control district, it rose modestly from 1.8% to 5.6% (95% CI: 4.0-7.3%). The odds of purchasing ACT within 24 hours in the intervention districts compared to the control was 0.46 (95% CI: 0.08-2.68, p=0.4) at baseline and significant increased to 6.11 (95% CI: 4.32-8.62, p<0.0001) at evaluation. Children less than five years of age had "ACT with a leaf" purchased for them more often than those aged above five years. There was no evidence of price gouging. CONCLUSIONS: These data demonstrate that a supply-side subsidy and an intensive communications campaign significantly increased the uptake and use of ACT in the private sector in Uganda.

Knowledge and malaria treatment practices using artemisinin combination therapy (ACT) in Malawi: survey of health professionals.

BACKGROUND: Malaria still remains a life-threatening disease worldwide causing between 190 and 311 million cases of malaria in 2008. Due to increased resistance to sulphadoxine-pyrimethamine (SP), the Ministry of Health in Malawi, as in many sub-Saharan African countries, changed the malaria treatment policy to use artemisinin-based combination therapy (ACT). In order to optimize the correct use of this drug, and protect against the development of the parasite's resistance, it is important to assess the knowledge and practices of medical practitioners on the use of ACT and its impact on adherence to new treatment policy guidelines. METHODS: A cross-sectional survey was conducted to assess the knowledge and perceptions of Malawian medical doctors and pharmacists on the use of ACT and the drivers of treatment choice and clinical treatment decisions. Medical doctors and pharmacists who are involved in managing malaria patients in Malawi were recruited and a self-administered questionnaire was used to obtain information on socio-demographic characteristics of the study participants, knowledge on ACT, source of information on ACT and methods used to decide on the treatment of patients with malaria. RESULTS: Most of the participants (95.7%) know at least one form of ACT, 67.4% reported that different forms of ACT have different characteristics, 77.3% reported that there are special formulations for children. The most commonly mentioned ACT was artemether-lumefantrine (AL), by 94.6% of the participants and 75.0% of the participants indicated that they prefer to prescribe AL. 73.9% of participants had ever received information on ACT. However, only 31.5% had received training on management of malaria using ACT. There were 71.7% respondents who had heard of ACT causing side effects. Only 25.0% of the participants had received training on how to report SAEs. CONCLUSION: It was found that most of the participants know about ACT and treatment guidelines for malaria. However, most of the participants have not received any training on how to use ACT and how to report adverse effects arising from the use of ACT. There is need for more training of health care professionals to ensure correct and effective use of ACT.

Understanding Market Size and Reporting Gaps for Paediatric TB in Indonesia, Nigeria and Pakistan: Supporting Improved Treatment of Childhood TB in the Advent of New Medicines.

OBJECTIVE OF THE STUDY: We sought to understand gaps in reporting childhood TB cases among public and private sector health facilities (dubbed "non-NTP" facilities) outside the network of national TB control programmes, and the resulting impact of under-reporting on estimates of paediatric disease burden and market demand for new medicines. METHODOLOGY: Exploratory assessments were carried out in Indonesia, Nigeria and Pakistan, reaching a range of facility types in two selected areas of each country. Record reviews and interviews of healthcare providers were carried out to assess numbers of unreported paediatric TB cases, diagnostic pathways followed and treatment regimens prescribed. MAIN FINDINGS: A total of 985 unreported diagnosed paediatric TB cases were identified over a three month period in 2013 in Indonesia from 64 facilities, 463 in Pakistan from 35 facilities and 24 in Nigeria from 20 facilities. These represent an absolute additional annualised yield to 2013 notifications reported to WHO of 15% for Indonesia, 2% for Nigeria and 7% for Pakistan. Only 12% of all facilities provided age and sex-disaggregated data. Findings highlight the challenges of confirming childhood TB. Diagnosis patterns in Nigeria highlight a very low suspicion for childhood TB. Providers note the need for paediatric medicines aligned to WHO recommendations. CONCLUSION HOW MARKET DATA CAN SUPPORT BETTER PUBLIC HEALTH INTERVENTIONS: This study emphasises the impact of incomplete reporting on the estimation of disease burden and potential market size of paediatric TB medicines. Further studies on "hubs" (facilities treating large numbers of childhood TB cases) will improve our understanding of the epidemic, support introduction efforts for new treatments and better measure markets for new paediatric medicines.

Burden of childhood tuberculosis in 22 high-burden countries: a mathematical modelling study.

BACKGROUND: Confirmation of a diagnosis of tuberculosis in children (aged <15 years) is challenging; under-reporting can result even when children do present to health services. Direct incidence estimates are unavailable, and WHO estimates build on paediatric notifications, with adjustment for incomplete surveillance by the same factor as adult notifications. We aimed to estimate the incidence of infection and disease in children, the prevalence of infection, and household exposure in the 22 countries with a high burden of the disease. METHODS: Within a mechanistic mathematical model, we combined estimates of adult tuberculosis prevalence in 2010, with aspects of the natural history of paediatric tuberculosis. In a household model, we estimated household exposure and infection. We accounted for the effects of age, BCG vaccination, and HIV infection. Additionally, we tested sensitivity to key structural assumptions by repeating all analyses without variation in BCG efficacy by latitude. FINDINGS: The median number of children estimated to be sharing a household with an individual with infectious tuberculosis in 2010 was 15,319,701 (IQR 13,766,297-17,061,821). In 2010, the median number of Mycobacterium tuberculosis infections in children was 7,591,759 (5,800,053-9,969,780), and 650,977 children (424,871-983,118) developed disease. Cumulative exposure meant that the median number of children with latent infection in 2010 was 53,234,854 (41,111,669-68,959,804). The model suggests that 35% (23-54) of paediatric cases of tuberculosis in the 15 countries reporting notifications by age in 2010 were detected. India is predicted to account for 27% (22-33) of the total burden of paediatric tuberculosis in the 22 countries. The predicted proportion of tuberculosis burden in children for each country correlated with incidence, varying between 4% and 21%. INTERPRETATION: Our model has shown that the incidence of paediatric tuberculosis is higher than the number of notifications, particularly in young children. Estimates of current household exposure and cumulative infection suggest an enormous opportunity for preventive treatment. FUNDING: UNITAID and the US Agency for International Development.